Stage IIA/B seminoma testis:retroperitoneal lymph node dissection as an alternative for chemotherapy and radiotherapy?

Standard of care for stage IIA seminoma testis (1–5 enlarged retroperitoneal lymph nodes ≤ 2 cm) and stage IIB-seminoma testis (lymph nodes 2–5 cm or &gt; 5 nodes) consists of chemotherapy or radiotherapy. These treatments increase the risk of cardiovascular morbidity, secondary malignancies and cause excess mortality at long-term follow-up. Recently, six cohort studies have investigated the efficacy of retroperitoneal lymph node dissection (RPLND) for stage IIA/B seminoma testis. It was shown that 70–80% of patients remain disease free after primary RPLND without adjuvant treatment. Although a minimally invasive (robot assisted) RPLND could be an alternative for chemotherapy or radiotherapy, a recurrence rate of 20–30% seems unacceptable. Risk-stratification is necessary to improve patient selection. In case of a higher recurrence risk a primary RPLND might be an option under the condition that a single cycle of chemotherapy is administered.</p

Distribution of Prostate Imaging Reporting and Data System score and diagnostic accuracy of magnetic resonance imaging–targeted biopsy: comparison of an Asian and European cohort

Background: This study aimed to compare the distribution of Prostate Imaging Reporting and Data System (PI-RADS) score and the diagnostic accuracy of magnetic resonance imaging (MRI)–targeted biopsy and systematic biopsy between a Chinese and a Dutch cohort. Materials and methods: Our study includes 316 men from Shanghai Changhai Hospital, China, and 266 men from the Erasmus University Medical Center, Rotterdam, the Netherlands. All men had a suspicion for prostate cancer (PCa) and were offered an multiparametric MRI (mpMRI) scan. Results: The distribution of the PI-RADS score was different between the two cohorts (P = 0.008). In the Chinese cohort of PI-RADS ≥3, the detection rate for high-grade PCa (Gleason ≥7) was 37.3% by systematic biopsy and 35.5% by MRI-targeted biopsy. The sensitivity of systematic biopsy was 0.80 for PCa and 0.75 for high-grade PCa. MRI-targeted biopsy achieved slightly higher sensitivity for PCa (0.82) and high-grade PCa (0.76). In the Dutch cohort of PI-RADS ≥3, the high-grade PCa detection rate was 44.4% and 54.5% for systematic biopsy and MRI-targeted biopsy. The sensitivity of systematic biopsy was 0.93 for PCa and 0.81 for high-grade PCa. By MRI-targeted biopsy, the sensitivity was 0.85 for PCa and 0.97 for high-grade PCa. Conclusions: The distribution of the PI-RADS score was different with more PI-RADS 4/5 in the Chinese cohort. Applying a PI-RADS ≥3 cutoff resulted in a favorable overall sensitivity. MRI-targeted biopsy showed a higher sensitivity in the detection of high-grade PCa than systematic biopsy. The sensitivity of MRI-targeted biopsy and systematic biopsy for both PCa and high-grade PCa in the Dutch cohort was superior to those in the Chinese cohort

Shifting risk-stratified early prostate cancer detection to a primary healthcare setting

Objective: To evaluate the feasibility of multivariable risk stratification for early prostate cancer (PCa) detection in a primary healthcare diagnostic facility with regard to its effects on the referral rate and subsequent PCa diagnoses compared to a PSA threshold of 3.0 ng/mL as the current referral indicator. Patients and  Methods: In 2014, the Erasmus MC Cancer Institute and the primary healthcare diagnostic facility STAR-SHL (located in Rotterdam city centre) initiated this observational study, in which general practitioners (GPs) could refer men who wished to undergo PCa screening to STAR-SHL for consultation by specially trained personnel. Referral recommendations to secondary healthcare were based on the outcome of application of the Rotterdam Prostate Cancer Risk Calculator (RPCRC) and were compared to the current Dutch GPs' PSA referral threshold of 3.0 ng/mL. For data collection on PCa diagnoses, the study cohort was linked to the Dutch nationwide pathology databank (PALGA).  Results: Between January 2014 and February 2021, 507 men were referred for consultation and in 495 men prostate-specific antigen (PSA) was tested. The median (interquartile range) follow-up from consultation to PALGA linkage was 43 (25–65) months. In total, 279 men (56%) had a PSA level ≥3.0 ng/mL, of whom 68% (95% confidence interval [95% CI] 63–74) were considered at low risk according to the RPCRC. Within 1 year after consultation, one of these men (0.52%; 95% CI 0.092–2.9) was diagnosed with clinically significant (cs)PCa (i.e., International Society of Urological Pathology Grade Group ≥2). Thereafter, another four (2.1%; 95% CI 0.82–5.3) low-risk men were diagnosed with csPCa. Of the high-risk men who were biopsied within 1 year after consultation (n = 61), 77% (95% CI 65–86) were diagnosed with PCa and 49% (95% CI 37–61) with csPCa.  Conclusion: In a primary healthcare diagnostic facility, the RPCRC could reduce up to 68% of referrals to secondary healthcare, as compared to a PSA referral threshold of 3.0 ng/mL. Deploying the RPCRC in this setting resulted in a high csPCa detection rate in those men biopsied. This strategy can be considered safe since the observational data showed low proportions of csPCa among men at low risk

Compliance Rates with the Prostate Cancer Research International Active Surveillance (PRIAS) Protocol and Disease Reclassification in Noncompliers

Background: Men with prostate cancer on active surveillance (AS) are advised to follow strict follow-up schedules and switch to definitive treatment on risk reclassification. However, some men might not adhere to these strict protocols. Objective: To determine the number of noncompliers and disease reclassification rates in men not complying with the follow-up protocol of the Prostate Cancer Research International Active Surveillance (PRIAS) study. Design, setting, and participants: A total of 4547 men with low-risk prostate cancer were included and prospectively followed on AS. Men were regularly examined using prostate-specific antigen (PSA), digital rectal examination, and repeat biopsies, and were advised to switch to definitive treatment on disease reclassification (>cT2c, Gleason score > 3 + 3, >2 cores positive, or PSA doubling time [PSA-DT] 0-3 yr). Outcome measurements and statistical analysis: Rates of men not complying with follow-up visits or a recommendation to discontinue AS are reported. Biopsy outcome (Gleason >= 7 or > 2 cores positive) was compared between compliers and noncompliers using Cox proportional hazards analysis. Results and limitations: The compliance rate for PSA visits was 91%. By contrast, the compliance rate for standard repeat biopsies decreased over time (81%, 60%, 53%, and 33% at 1, 4, 7, and 10 yr after diagnosis, respectively). Yearly repeat biopsies in men with faster rising PSA (PSA-DT 3-10 yr) was low at < 30%, although these men had higher upgrading rates at repeat biopsy (25-30% vs 16%). PSA-DT of 0-3 yr was the most common recommendation for discontinuation, but 71% continued on AS. Men with PSADT of 0-3 yr were at higher risk of upgrading on repeat biopsy (hazard ratio 2.02, 95% confidence interval 1.36-3.00) compared to men without fast rising PSA. Conclusion: Some men and their physicians do not comply with AS follow-up protocols. In particular, yearly repeat biopsies in men with fast rising PSA are often ignored, as is the recommendation to discontinue AS because of very fast rising PSA. Although these men are at greater risk of higher Gleason scores on repeat biopsy, the majority still exhibit favorable tumor characteristics. Fast rising PSA should therefore not trigger a recommendation to receive active treatment, but should rather serve as a criterion for stricter follow-up. In addition, we should aim to find ways of safely reducing the number of biopsies to increase adherence to AS protocols. Patient summary: Welooked at compliance with an active surveillance protocol for low-risk prostate cancer in a large active surveillance study. We observed reluctance to undergo yearly biopsies because of fast rising prostate-specific antigen, despite a higher risk of disease progression. Further research should aim to safely reduce the number of repeat biopsies in men on active surveillance to increase protocol adherence. (C) 2015 European Association of Urology. Published by Elsevier B.V. All rights reserved

Biomarker-oriented therapy in bladder and renal cancer

Treatment of patients with urothelial carcinoma (UC) of the bladder or renal cancer has changed significantly during recent years and efforts towards biomarker-directed therapy are being investigated. Immune checkpoint inhibition (ICI) or fibroblast growth factor receptor (FGFR) directed therapy are being evaluated for non-muscle invasive bladder cancer (NMIBC) patients, as well as muscle-invasive bladder cancer (MIBC) patients. Meanwhile, efforts to predict tumor response to neoadjuvant chemotherapy (NAC) are still ongoing, and genomic biomarkers are being evaluated in prospective clinical trials. Currently, patients with metastatic UC (mUC) are usually treated with second-line ICI, while cisplatin-ineligible patients with programmed death-ligand 1 (PD-L1) positive tumors can benefit from first-line ICI. Platinum-relapsed UC patients harboring FGFR2/3 mutations can be treated with erdafitinib, while enfortumab vedotin has emerged as a novel third-line treatment option for mUC. In metastatic (clear cell) renal cell carcinoma (RCC), ICI was first introduced as second-line treatment after vascular endothelial growth factor receptor—tyrosine kinase inhibition (VEGFR-TKI). Currently, ICIs have also been introduced as first-line treatment in metastatic RCC. Although there is no evidence up to now for beneficial adjuvant treatment after surgery with VEGFR-TKIs in high-risk non-metastatic RCC, several trials are underway investigating the potential beneficial effect of ICIs in this setting

Data for: Distribution of PI-RADS Score and Diagnostic Accuracy of MRI-targeted Biopsy: Comparison of an Asian and European Cohort

Distribution of PI-RADS Score and Diagnostic Accuracy of MRI-targeted Biopsy: Comparison of an Asian and European Cohor

Characteristics of Prostate Cancer Found at Fifth Screening in the European Randomized Study of Screening for Prostate Cancer Rotterdam: Can We Selectively Detect High-grade Prostate Cancer with Upfront Multivariable Risk Stratification and Magnetic Resonance Imaging?

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